Provider Demographics
NPI:1588823306
Name:CLARKE, DOROTHY W (MA RD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:W
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MA RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 WALDORF DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2818
Mailing Address - Country:US
Mailing Address - Phone:937-681-5736
Mailing Address - Fax:937-274-2886
Practice Address - Street 1:405 W GRAND
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405
Practice Address - Country:US
Practice Address - Phone:937-723-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5013133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5013OtherLICENCE
OH857998OtherREGISTERED DIETITIAN